Blimey – I can’t believe it’s 2 YEARS since I last posted! Only seems like last month …
I promise I’ve been busy though.
It’s often said that the best committees are composed of two people, one of whom doesn’t turn up. Midlife is committee time (it’s no wonder Gen X are unhappy!) and they’re usually pretty turgid affairs: the same people repeating the same positions, only agreeing on the need for another meeting. occasionally though, something really useful happens, and really easily.
I’ve been a supporter of the (International) Fragility Fractures Network since its creation a decade ago. As part of its mission to ‘optimise globally the multidisciplinary management of the patient with a fragility fracture’, the FFN focuses on producing consensus guidelines. Just after my last post, I was lucky enough to be elected onto the Board of the FFN, and thought that this might be a great opportunity to try and convene some consensus guidelines on the anaesthetic management of hip fracture patients.
I’d previously helped write the AAGBI 2011 hip fracture anaesthesia guidelines (2018 update imminent!), which have been well received in the UK and abroad, but are quite UK-centric. I wondered whether it might be possible to produce some statements about what a hip fracture patient should expect from anaesthesia and anaesthetists anywhere in the World. So I asked 28 expert hip fracture anaesthetists from all around the World to submit as many statements as they wanted about what ‘good hip fracture anaesthesia’ looks like.
And the most amazing thing happened – all 28 experts described ‘good hip fracture anaesthesia’ in roughly the same way! Anaesthetists (and even one orthopaedic surgeon) agreeing at the first time of asking – who would have thought? Made the rest of the 2-year process much easier …
The submitted statements were condensed into themed statements, the experts voted on whether they agreed with these (with an 80% cut-off), the accepted statements were condensed further into 7 principles (with supporting information), a paper written (signed off by all the experts) and submitted to Anaesthesia – and published today!
I’ll leave you to read the paper for yourselves – and would love to know your thoughts on it – but thought I might just write what I think the highlights are.
Firstly, as I mentioned above, there was a lot of consensus. Now, I agree that ‘for every expert there is an equal and opposite expert’, but the co-signatories span the opinion range, as well as having a wealth of clinical and academic experience between them, both clinically and academically.
Some of the statements we agreed on may appear rather neutral, but we were mindful of making them applicable to all patients in all countries. The paper carries all the themed statements voted for and, as you can see, some of the more contentious were rejected in favour of broader consensus. For example, ‘offer either regional or general anaesthesia, plus nerve block’ was accepted, but not ‘regional anaesthesia is preferred to general anaesthesia’, which I think (despite my own opinion and last blog post) is a pretty fair reflection of the current evidence.
Thirdly, the paper should help empower anaesthetists in perhaps more hierarchical surgical systems to challenge poor care where they see it. Much of the paper describes crucial organisational changes that anaesthetists need to be involved with or lead, mainly with the aim of getting hip fracture patients to theatre within 48 hours. You’ll notice too that there’s heavy emphasis on standardising care where possible – standardise until you have to improvise!
Finally, rather than prescribe exactly how to give an anaesthetic, the paper emphasises that the purpose of anaesthesia is to help hip fracture patients remobilise (i.e. get up walking ASAP after surgery), re-enable (i.e. get back to normal function) and rehabilitate (i.e. get home again). We’re no longer aiming just to get hip fracture patients to the PACU, but we’re starting their recovery: give a bloody good anaesthetic and help them help themselves back to health!